The relationship between the source of oral health information and dental caries: Findings from Child Dental Health Survey 2013 in England

Objective To determine the magnitude and shape of the relationship between dental caries experience and the source of oral health information in England. Methods This was a cross-sectional study using the Child Dental Health Survey 2013 in England. Using a negative binomial model, the relationship between the number of decayed, missing, filled teeth (DMFT) of 12- and 15-year-old students and their primary source of oral health information was assessed. The sources of oral health information included parents, television, newspapers, the Internet, and social media. The adjusted model included age, sex, and the Index of Multiple Deprivation (IMD). R was used for data handling, analysis and reporting. Results Overall, 2,372 children were assessed (48.7% female, 48.6% 12-year-old). For the majority, the primary source of oral health information was their parents (89.5%) followed by the Internet (43.4%). Over nine-tenth of the participants had a DMFT = 0. The adjusted model showed that the prevalence rate of DMFT for the children whose primary source of information is their parents (0.45) or television (0.62) is lower than 1. The prevalence rate for the Internet (1.17) and social media (1.67) was higher than 1, but they were removed from the final model due to being non-statistically significant. Age and deprivation had a direct relationship with the prevalence rate of DMFT, meaning that 15-year-olds and children from more deprived areas had a higher prevalence rate of DMFT. Conclusion Children whose primary source of oral health information was their parents or television had a lower DMFT. On the contrary, using the Internet or social media as the source of oral health information was associated with higher caries experience among schoolchildren.

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The relationship between the source of oral health information and dental caries: Findings from Child Dental

Health Survey 2013 in England
Ahmad Sofi-Mahmudi* 1,2 , ORCiD: 0000-0001-6829-0823  (5).By empowering individuals with this knowledge, oral health education not only helps prevent dental problems but also encourages early intervention and treatment, ultimately contributing to improved overall oral health and well-being.
Previous research has focused on the effect of a specific source of information on oral health.
However, the question of which one of these sources plays a more important role has remained unanswered.Therefore, the aim of this research article is to determine the relationship between the sources of oral health information and the number of decayed, missing, filled teeth (DMFT) among 12-and 15-year-old children living in England in 2013.

Methods
All codes and metadata related to the study were shared via its OSF repository (https://osf.io/2vazm/)at the time of submission of the manuscript.Additional comprehensive information regarding the survey's design has been previously published elsewhere (6).

Source of the data
Possible sources of information in this dataset include parents, TV, newspapers and magazines, the internet, and social media.Permanent teeth caries experience (DMFT) was considered as the dependent variable; therefore, I only included 12-and 15-year-olds.Age, sex, and deprivation level (based on country-specific Indices of Multiple Deprivation or IMD) were used for model adjustment.
Is this a prerequisite in this journal and must it be included?
Rephrase-Study Design this was a retrospective cross sectional study using the CDHS 2023 data....

Data analysis
As DMFT is count data, regression models with count data distributions were chosen.Among them, Poisson regression is the most widely used.However, since the data showed over-dispersion, a negative binomial regression was used.Overdispersion was confirmed by comparing the mean (0.19) and standard deviation (0.79) of DMFT.Also, the result of the overdispersion test showed an overdispersion estimate of 1.95 (p<0.001).

Descriptive statistics
This dataset included 2,372 children from England.Of these, 51.3% were male, and 48.7% were female.DMFT (outcome of interest) was a highly skewed variable with many zeros; therefore, both the median and interquartile range were 0. In Table 1, frequencies and weight-adjusted proportions are reported for age groups, IMD, and sources of information.

Hypothesis testing
Eight different models were constructed: five for the unadjusted relationship between DMFT and each source of oral health information; one with all sources; one with all sources and adjusted for sociodemographic variables; and the final model.The value of the intercept in the negative binomial model stands for the expected (average) value of the count dependent variable when the values of all predictor variables in the dataset are set to 0. Here, the expected value of DMFT when all other variables are 0 is expected to be in the range of 0.17-0.59.
All the following numbers are from adjusted models.Therefore, they are the estimates for the degree of association between each variable and DMFT, holding all other variables in the model constant.
When all sources of oral health information and sociodemographic variables were added in model 7, two sources (internet and social media) and two demographic variables (being of age 15 and female) had a direct relationship with DMFT.It means that schoolchildren using these sources, girls, and those aged 15, had more tooth decay experience (higher prevalence rate ratio).However, three sources, newspapers and magazines, the internet and social media, and sex, did not have a significant relationship with DMFT.Therefore, they were excluded from the final model.
The final model includes parents and TV as sources of oral health information, as well as age and deprivation as sociodemographic variables.This model shows that the expected DMFT for schoolchildren receiving information from their parents was 0.45 times the expected DMFT for schoolchildren who did not receive such information from their parents.Also, schoolchildren who used a TV as a source had a 38% lower rate of DMFT on average than those who did not use a TV.
Fifteen-year-olds had a 47% higher prevalence rate of DMFT compared with 12-year-olds.
Looking at IMD quintiles (categorical variable) reveals a gradient that schoolchildren from less deprived backgrounds had a lower rate of DMFT on average compared to those from the most deprived category.For instance, the two least deprived categories (IMD 5 th and 4 th ) had 83% lower prevalence rates of DMFT compared with the most deprived category (IMD 1 st , the reference group).

Testing model fitness
When comparing the final model with model 7 (including all variables) using the likelihood ratio test, the associated chi-squared value was -6.56 (df=4, p=1).Therefore, there is no evidence that the final model underperforms compared with the model with all the variables.

Checking model assumptions
Negative binomial models assume the conditional means are not equal to the conditional variances.

Discussion
This study showed a decrease in the prevalence rate of DMFT in students whose sources for oral health information were their parents (0.45) or TV (0.62).Fifteen-year-olds and students from deprived areas had a higher prevalence rate.The prevalence rate for newspaper was lower than 1, and for the Internet and social media, were higher than 1; however, these were not statistically significant.
The lower prevalence rate for parents can be linked to socioeconomic status, as parents who are more vigilant about their children's oral health and provide guidance tend to experience less deprivation (7,8).Higher socioeconomic status affords parents improved access to education and oral health information, making them more aware of the significance of proper oral hygiene and dental care practices (9).Consequently, these parents often impart their knowledge to their children, emphasizing the importance of regular dental check-ups, correct brushing techniques, and a healthful diet.
Moreover, socioeconomic status can significantly shape dietary choices within households.
Families with higher incomes tend to enjoy greater access to nutritious foods and snacks, thereby contributing to enhanced oral health outcomes (10).Conversely, lower-income families may find themselves relying more on processed foods and sugary snacks, recognized culprits in dental decay.
In this study, an intriguing pattern emerged regarding the sources of oral health information among children.Those who relied on TV as their primary source were less likely to experience dental caries, while the Internet and social media were associated with a higher prevalence rate of dental caries (DMFT).This divergence in outcomes can be attributed to several factors related to the nature and oversight of these information sources.
Television, as a medium, offers better controllability when compared to the Internet and social media.TV programs operate within a centralized framework and typically undergo more rigorous quality checks before content is broadcasted.Consequently, the information presented on TV tends to be curated, reliable, and accurate, contributing to better dental health outcomes.
Furthermore, the role of parental involvement cannot be understated.Parents often monitor and guide their children's TV viewing habits, ensuring that they are exposed to educational content related to oral health (11).This proactive engagement by parents serves to reinforce the oral health messages conveyed through TV, encouraging children to adopt and practice good oral hygiene habits.
In contrast, the Internet and social media represent decentralized systems where anyone can post information, much of which may be inaccurate or misleading (12).Unfortunately, children's use of these platforms is not always subject to parental supervision or guidance.This lack of oversight can result in children accessing unreliable sources of information and potentially adopting less effective oral health practices.For example, children might be influenced by friends or online influencers who engage in behaviours like excessive sugary food consumption or neglecting oral hygiene.

Limitations
Because of the excessive number of zeros in the DMFT variable in this dataset, it is suggested to use a zero-inflated negative binomial regression (3).Zero DMFT may be because of different processes, such as receiving fluoridated water.A standard negative binomial model does not distinguish between processes that lead to zeros, but a zero-inflated model allows for and accommodates this complication.The same as above was done here for comparing the final model with a zero-inflated one.The associated chi-squared value was 2.51 (df=4, p=0.643).Therefore, using a non-zero-inflated model is preferable due to its simplicity.

Conclusion
Children whose primary source of oral health information was their parents or TV had a lower DMFT.On the contrary, using the Internet or social media as the source of oral health information was associated with higher caries experience among schoolchildren.
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used the Child Dental Health Survey (CDHS) 2013 dataset to answer the research question.The CDHS 2013 represents the fifth installment within the sequence of decennial cross-sectional national surveys conducted in the United Kingdom, focusing on children's health.The study encompassed students aged 5, 8, 12, and 15 who were enrolled in mainstream state and independent schools across England, Wales, and Northern Ireland.The survey encompassed a total of 13,628 students.Data acquisition for the CDHS 2013 involved multiple methods, including a clinical dental examination, a self-completion questionnaire administered to older children, and a parental questionnaire.For younger children, parental consent was obtained through a written optin process, while older children followed an opt-out procedure.The Research Ethics Committee at University College London granted approval for the CDHS 2013 (Project ID: 2000/003).
This text is appropriate if the data are owned by a third party and authors do not have permission to share the data.
Powered by Editorial Manager® and ProduXion Manager® from Aries Systems CorporationThe data underlying the results presented in the study are available from (include the name of the third party • All metadata and codes are available from https://osf.io/2vazm/.Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation and contact information or URL).

1
National Pain Centre, Department of Anesthesia, McMaster University, Hamilton, ON, Canada.
(4)epartment of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.Corresponding author: Ahmad Sofi-Mahmudi; Address: MDCL 2109, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada; Telephone: +1 (905) 525-9140 ext.22743;Email: sofima@mcmaster.ca,a.sofimahmudi@gmail.com.IntroductionDespite being largely preventable, dental caries persists as a substantial global health concern(1).Effective communication and education about oral health may be crucial in preventing dental caries, particularly among children(4).Such oral health education plans can be about oral hygiene or the detrimental effects of poor dietary choices, tobacco use, and excessive alcohol consumption on oral health.Various sources, such as dental professionals, schools, parents, and media, play pivotal roles in disseminating oral health information

Table 1 .
Descriptive statistics of included variables Dont start a sentence with abbreviation rather use "The DMFT" remove outcome of interest-you are writing for a scientific audience so this should be obvious to them.

Table 2 .
Table 2 depicts the summary for each model.I should note that the numbers for categorical variables are (prevalence) rate ratios.All numbers in Table 2 are back-transformed from their logarithm provided by the statistical software.Here, we scrutinize models 6-8.The results of different regression models (2)s inequality is captured by estimating a dispersion parameter that is held constant in a Poisson model.Thus, the Poisson model is actually nested in the negative binomial model(2).I used a likelihood ratio test to compare these two and test this model assumption.The associated chi-squared value was 626.56 with 4 degrees of freedom (p<0.001).This strongly suggests the negative binomial model, estimating the dispersion parameter, is more appropriate than the Poisson model.